Emergency Medical Services Innovation: Comparison of Outcomes for Access and Referral in Two North Carolina Systems

Too many patients with low acuity medical problems access Emergency Medical Services (EMS) and Emergency Departments (EDs) for care. EMS is a key component of the health care system. Historically, its function was to provide care for people who experience emergencies, transporting them to hospital EDs for further definitive diagnosis and treatment. Over the last two decades, EMS is caring for a growing percentage of people accessing 9-1-1 for less than serious emergency conditions. This phenomenon is an element of a health care crisis that includes rapidly escalating costs, increasing numbers of uninsured, poor access to consistent primary care and comparatively mediocre health outcomes. With crowded EDs, EMS innovators have been exploring alternatives to relieve these structural pressures by diverting patients from EDs to other venues, particularly primary care providers (PCPs). This study compares two alternatives in North Carolina. There are two models that have been piloted. The first found in Orange County involves an EMS response to every 911 request. Once a paramedic evaluates a patient, it is decided if transport to the ED is warranted or whether the patient can be treated on-scene and referred to their PCP. The second model employs a telephone triage system in which requests for service of a low severity type are diverted from the 911 call center to nurse call centers. Nurses use an evidenced-based, medically approved protocol to make the determination if the patient does not need an EMS response and, if not, provides advice to the patient and refers them to their PCP. More significant emergencies receive the normal EMS response that results in care and transport to the ED. Using primary data from the two service quality improvement programs, the primary question is whether there is a significant difference in effectiveness between the Evaluate, Treat and Refer (ETR) intervention and the Telephone Triage and Refer (TTR) intervention as measured by patient follow through with instructions for the referral to primary care and patient satisfaction. Major findings were that there was a significant difference between the two alternatives in that odds were greater that low acuity callers in Mecklenburg County would follow instructions for referral/and or self-care than the low acuity patients evaluated in person in Orange County. Patient satisfaction was high for both alternatives with only slightly higher odds that patients in Orange County would be satisfied. The Orange County ETR alternative used the ETR on a broader spectrum of patient conditions as compared to more conservative criteria used in the Mecklenburg County TTR alternative. This factor may explain the significant difference in following instructions. The high patient satisfaction rates for both alternatives is an indication people with low acuity but urgent medical problems are willing to accept alternatives to transport and treatment in the ED and high percentages follow the instructions given. While the Mecklenburg TTR model was less costly and had higher odds that patients would follow instructions, it entered a narrower range of patient problems into its alternative pathway. More research is needed to explore the difference in outcomes and patient behaviors of these alternatives and to examine hybrid systems that combine both TTR and ETR